Measuring Contraceptive Autonomy at Two Sites in Burkina Faso: A First Attempt to Measure a Novel Family Planning Indicator.

There is growing consensus in the family planning community around the need for novel measures of autonomy. Existing literature highlights the tension between efforts to pursue contraceptive targets and maximize uptake on the one hand, and efforts to promote quality, person-centeredness, and contraceptive autonomy on the other hand. Here, we pilot a novel measure of contraceptive autonomy, measuring it at two Health and Demographic Surveillance System sites in Burkina Faso. We conducted a population-based survey with 3,929 women of reproductive age, testing an array of new survey items within the three subdomains of informed choice, full choice, and free choice. In addition to providing tentative estimates of the prevalence of contraceptive autonomy and its subdomains in our sample of Burkinabè women, we critically examine which parts of the proposed methodology worked well, what challenges/limitations we encountered, and what next steps might be for refining, improving, and validating the indicator. We demonstrate that contraceptive autonomy can be measured at the population level but a number of complex measurement challenges remain. Rather than a final validated tool, we consider this a step on a long road toward a more person-centered measurement agenda for the global family planning community.

Assessing the Suitability of Unmet Need as a Proxy for Access to Contraception and Desire to Use It.

Unmet need for contraception is a widely used but frequently misunderstood indicator. Although calculated from measures of pregnancy intention and current contraceptive use, unmet need is commonly used as a proxy measure for (1) lack of access to contraception and (2) desire to use it. Using data from a survey in Burkina Faso, we examine the extent to which unmet need corresponds with and diverges from these two concepts, calculating sensitivity, specificity, and positive/negative predictive values. Among women assigned conventional unmet need, 67 percent report no desire to use contraception and 61 percent report access to a broad range of affordable contraceptives. Results show unmet need has low sensitivity and specificity in differentiating those who lack access and/or who desire to use a method from those who do not. These findings suggest that unmet need is of limited utility to inform family planning programs and may be leading stakeholders to overestimate the proportion of women in need of expanded family planning services. We conclude that more direct measures are feasible at the population level, rendering the proxy measure of unmet need unnecessary. Where access to and/or desire for contraception are the true outcomes of interest, more direct measures should be used.

Contraceptive stockouts in Western Kenya: a mixed-methods mystery client study.

BACKGROUND: The prevalence of modern contraception use is higher in Kenya than in most countries in Sub-Saharan Africa. The uptake has however slowed down in recent years, which, among other factors, has been attributed to challenges in the supply chain and increasing stockouts of family planning commodities. Research on the frequency of contraceptive stockouts and its consequences for women in Kenya is still limited and mainly based on facility audits. METHODS: This study employs a set of methods that includes mystery clients, focus group discussions, key informant interviews, and journey mapping workshops. Using this multi-method approach, we aim to quantify the frequency of method denial resulting from contraceptive stockout and describe the impact of stockouts on the lived experiences of women seeking contraception in Western Kenya. RESULTS: Contraceptives were found to be out of stock in 19% of visits made to health facilities by mystery clients, with all contraceptive methods stocked out in 9% of visits. Women experienced stockouts as a sizeable barrier to accessing their preferred method of contraception and a reason for taking up non-preferred methods, which has dire consequences for heath, autonomy, and the ability to prevent unintended pregnancy. Reasons for contraceptive stockouts are many and complex, and often linked to challenges in the supply chain - including inefficient planning, procurement, and distribution of family planning commodities. CONCLUSIONS: Contraceptive stockouts are frequent and negatively impact patients, providers, and communities. Based on the findings of this study, the authors identify areas where funding and sustained action have the potential to ameliorate the frequency and severity of contraceptive stockouts, including more regular deliveries, in-person data collection, and use of data for forecasting, and point to areas where further research is needed.

Evaluating the feasibility of the Community Score Card and subsequent contraceptive behavior in Kisumu, Kenya.

BACKGROUND: Women seeking family planning services from public-sector facilities in low- and middle-income countries sometimes face provider-imposed barriers to care. Social accountability is an approach that could address provider-imposed barriers by empowering communities to hold their service providers to account for service quality. Yet little is known about the feasibility and potential impact of such efforts in the context of contraceptive care. We piloted a social accountability intervention-the Community Score Card (CSC)-in three public healthcare facilities in western Kenya and use a mix of quantitative and qualitative methodologies to describe the feasibility and impact on family planning service provision. METHODS: We implemented and evaluated the CSC in a convenience sample of three public-sector facility-community dyads in Kisumu County, Kenya. Within each dyad, communities met to identify and prioritize needs, develop corresponding indicators, and used a score card to rate the quality of family planning service provision and monitor improvement. To ensure young, unmarried people had a voice in identifying the unique challenges they face, youth working groups (YWG) led all CSC activities. The feasibility and impact of CSC activities were evaluated using mystery client visits, unannounced visits, focus group discussions with YWG members and providers, repeated assessment of score card indicators, and service delivery statistics. RESULTS: The involvement of community health volunteers and supportive community members - as well as the willingness of some providers to consider changes to their own behaviors-were key score card facilitators. Conversely, community bias against family planning was a barrier to wider participation in score card activities and the intractability of some provider behaviors led to only small shifts in quality improvement. Service statistics did not reveal an increase in the percent of women receiving family planning services. CONCLUSION: Successful and impactful implementation of the CSC in the Kenyan context requires intensive community and provider sensitization, and pandemic conditions may have muted the impact on contraceptive uptake in this small pilot effort. Further investigation is needed to understand whether the CSC - or other social accountability efforts - can result in improved contraceptive access.

Contraceptive Autonomy: Conceptions and Measurement of a Novel Family Planning Indicator.

Since the 1994 International Conference on Population and Development, there has been increased attention to high-quality and rights-based family planning, but these concepts have been difficult to measure. Perhaps due to an intellectual history intertwined with population control, contemporary family planning programs and researchers often use (modern) method use as a primary marker of success, with indicators focusing narrowly on contraceptive use and fertility. This results in a fundamental misalignment between existing metrics and the stated family planning goals of promoting reproductive health and rights. This report describes the rationale for a novel family planning indicator called "contraceptive autonomy" and proposes a methodology for measuring this concept at the population level. Defining contraceptive autonomy as the factors necessary for a person to decide for themself what they want in relation to contraception and then to realize that decision, this indicator divides the contraceptive autonomy construct into subdomains of informed choice, full choice, and free choice. By acknowledging that autonomous nonuse is a positive outcome,aiming to maximize contraceptive autonomy rather than use could help shift incentives for family planning programs and reduce some common forms of contraceptive coercion, as our measurement approach is realigned with our focus on high-quality rights-based care.

Effect of a postpartum family planning intervention on postpartum intrauterine device counseling and choice: evidence from a cluster-randomized trial in Tanzania.

BACKGROUND: The World Health Organization recommends postpartum family planning (PPFP) for healthy birth spacing. This study is an evaluation of an intervention that sought to improve women's access to PPFP in Tanzania. The intervention included counseling on PPFP during antenatal and delivery care and introducing postpartum intrauterine device (PPIUD) insertion as an integrated part of delivery services for women electing PPIUD in the immediate postpartum period. METHODS: This cluster-randomized controlled trial recruited 15,264 postpartum Tanzanian women aged 18 or older who delivered in one of five study hospitals between January and September 2016. We present the effectiveness of the intervention using a difference-in-differences approach to compare outcomes, receipt of PPIUD counseling and choice of PPIUD after delivery, between the pre- and post-intervention period in the treatment and control group. We also present an intervention adherence-adjusted analysis using an instrumental variables estimation. RESULTS: We estimate linear probability models to obtain effect sizes in percentage points (pp). The intervention increased PPIUD counseling by 19.8 pp (95% CI: 9.1 - 22.6 pp) and choice of PPIUD by 6.3 pp (95% CI: 2.3 - 8.0 pp). The adherence-adjusted estimates demonstrate that if all women had been counseled, we would have observed a 31.6 pp increase in choice of PPIUD (95% CI: 24.3 - 35.8 pp). Among women counseled, determinants of choosing PPIUD included receiving an informational leaflet during counseling and being counseled after admission for delivery services. CONCLUSIONS: The intervention modestly increased the rate of PPIUD counseling and choice of PPIUD, primarily due to low coverage of PPIUD counseling among women delivering in study facilities. With universal PPIUD counseling, large increases in choice of PPIUD would have been observed. Giving women informational materials on PPIUD and counseling after admission for delivery are likely to increase the proportion of women choosing PPIUD. TRIAL REGISTRATION: Registered with clinicaltrials.gov (NCT02718222) on March 24, 2016, retrospectively registered.

Women's Perspectives on Postpartum Intrauterine Devices in Tanzania.

Despite the numerous benefits of the postpartum copper intrauterine device (PPIUD), which is inserted within 48 hours after giving birth, it is underutilized in many resource-constrained settings, including Tanzania. We conducted in-depth interviews with 20 pregnant women who received contraceptive counseling during routine antenatal care in 2016-2017 and 27 postpartum women who had a PPIUD inserted in 2018 to understand reasons for use versus nonuse and continuation versus discontinuation. Primary motivators for using a PPIUD included: convenience, effectiveness, perceived lack of side effects, and duration of pregnancy protection. Barriers to use included: fear of insertion, concerns related to sexual experiences post-insertion, and limited knowledge. Women who had a PPIUD inserted continued use when their expectations matched their experience, while discontinuation resulted from unexpected expulsion and experience of unanticipated side effects. Frequent follow-up and guidance on side-effect management influenced women's decisions to continue use. To support uptake and continued utilization of the PPIUD, postpartum contraceptive counseling should explicitly address side effects and risk of expulsion.

Institutionalizing postpartum intrauterine device (IUD) services in Sri Lanka, Tanzania, and Nepal: study protocol for a cluster-randomized stepped-wedge trial.

BACKGROUND: During the year following the birth of a child, 40% of women are estimated to have an unmet need for contraception. The copper IUD provides safe, effective, convenient, and long-term contraceptive protection that does not interfere with breastfeeding during the postpartum period. Postpartum IUD (PPIUD) insertion should be performed by a trained provider in the early postpartum period to reduce expulsion rates and complications, but these services are not widely available. The International Federation of Obstetricians and Gynecologists (FIGO) will implement an intervention that aims to institutionalize PPIUD training as a regular part of the OB/GYN training program and to integrate it as part of the standard practice at the time of delivery in intervention hospitals. METHODS: This trial uses a cluster-randomized stepped wedge design to assess the causal effect of the FIGO intervention on the uptake and continued use of PPIUD and of the effect on subsequent pregnancy and birth. This trial also seeks to measure institutionalization of PPIUD services in study hospitals and diffusion of these services to other providers and health facilities. This study will also include a nested mixed-methods performance evaluation to describe intervention implementation. DISCUSSION: This study will provide critical evidence on the causal effects of hospital-based PPIUD provision on contraceptive choices and reproductive health outcomes, as well as on the feasibility, acceptability and longer run institutional impacts in three low- and middle-income countries. TRIAL REGISTRATION: Trial registered on March 11, 2016 with ClinicalTrials.gov, NCT02718222 .

Perceptions of access to long-acting reversible contraception removal among women in Burkina Faso.

OBJECTIVES: Long-acting reversible contraception (LARC) initiation has been well-studied and intervened upon. Because LARC requires provider intervention for initiation and removal, it is critical to measure informed choice at the time of desired discontinuation as well. We examined perceptions of access to LARC discontinuation among women at two sites in Burkina Faso, where LARC is the dominant method in the contraceptive mix. STUDY DESIGN: We analyzed data from a 2017-2018 population-based, cross-sectional survey of 281 implant users and 55 intrauterine device users at two sites in Burkina Faso. We measured perceptions of access to LARC discontinuation through survey items assessing whether participants (1) were informed on how to discontinue the method, (2) believed they could have LARC removed without a lot of difficulty, (3) believed cost would be a barrier to discontinuation, (4) had ever attempted to have a provider remove LARC, and (5) successfully had LARC removed. The distribution of these measures was examined in the population and for differences by gravida, parity, domestic partnership, fertility desires, and recency of last childbirth. RESULTS: Thirty-eight (11%) of current LARC users reported that they were not informed on how to discontinue, 56 (17%) believed having their device removed would be difficult, and 54 (16%) believed cost would be a barrier to removal. Of women who attempted removal, providers did not immediately remove LARC on request for 10 (28%). CONCLUSIONS: Findings indicate that LARC uptake is an insufficient measure of reproductive access or choice. Future studies should include patient-centered measures that span the full duration of contraceptive use. IMPLICATIONS: This paper finds that a sizable proportion of LARC users lack information about method discontinuation and perceive or experience barriers to method removal. These findings call for a reconsideration of free and informed contraceptive choice to include the entire duration of contraceptive use, not only the time of method provision.

The effect of a postpartum intrauterine device programme on choice of contraceptive method in Tanzania: a secondary analysis of a cluster-randomized trial.

Vertical global health programmes often evaluate success with a narrow focus on programmatic outcomes. However, evaluation of broader patient-centred and unintended outcomes is critical to assess impacts on patient choice and autonomy. Here, we evaluate the effects of a postpartum intrauterine device (PPIUD) intervention on outcomes related to contraceptive method choice. The stepped-wedge cluster randomized contolled trial (RCT) took place in five Tanzanian hospitals. Hospitals were randomized to receive immediate (Group 1; n = 11 483 participants) or delayed (Group 2; n = 8148 participants) intervention. The intervention trained providers on PPIUD insertion and counselling. The evaluation surveyed eligible women (18+, resided in Tanzania, gave birth at a study hospital) on provider postpartum contraceptive counselling during pregnancy or immediately postpartum. In our completed study, participants were considered exposed (n = 9786) or unexposed (n = 10 145) to the intervention based on the location and timing of their birth (no blinding). Our secondary analysis examined differences by intervention exposure on the likelihood of being counselled on IUD only, multiple methods, multiple method durations, a broad method mix; and on the number of methods women were counselled across two samples: all eligible women, and only women who reported receiving any contraceptive counselling. Among all eligible women, counselling on the IUD alone was 7% points higher among the exposed (95% confidence interal (CI): 0.02, 0.12). Among women who received any counselling, those exposed to the intervention were counselled on 1.12 fewer contraceptive methods (95% CI: 0.10, 2.34). The likelihood of receiving counselling on any non-IUD method decreased among those exposed, while the likelihood of being counselled on an IUD alone was 14% points higher among the exposed (95% CI: 0.06, 0.22), suggesting this intervention increased IUD-specific counselling but reduced informed contraceptive choice. These findings underscore the importance of broad metrics that capture autonomy and rights (in addition to programmatic goals) at all stages of health programme planning and implementation.

Health care provider bias in the Appalachian region: The frequency and impact of contraceptive coercion.

OBJECTIVE: To investigate the frequency and impact of contraceptive coercion in the Appalachian region of the United States. DATA SOURCES AND STUDY SETTING: In fall 2019, we collected primary survey data with participants in the Appalachian region. STUDY DESIGN: We conducted an online survey including patient-centered measures of contraceptive care and behavior. DATA COLLECTION/EXTRACTION METHODS: We used social media advertisements to recruit Appalachians of reproductive age who were assigned female at birth (N = 622). After exploring the frequency of upward coercion (pressure to use contraception) and downward coercion (pressure not to use contraception), we ran chi-square and logistic regression analyses to explore the relationships between contraceptive coercion and preferred contraceptive use. PRINCIPAL FINDINGS: Approximately one in four (23%, n = 143) participants reported that they were not using their preferred contraceptive method. More than one-third of participants (37.0%, n = 230) reported ever experiencing coercion in their contraceptive care, with 15.8% reporting downward coercion and 29.6% reporting upward coercion. Chi-square tests indicated that downward (χ2 (1) = 23.337, p < 0.001) and upward coercion (χ2 (1) = 24.481, p < 0.001) were both associated with a decreased likelihood of using the preferred contraceptive method. These relationships remained significant when controlling for sociodemographic factors in a logistic regression model (downward coercion: Marginal effect = -0.169, p = 0.001; upward coercion: Marginal effect = -0.121, p = 0.002). CONCLUSIONS: This study utilized novel person-centered measures to investigate contraceptive coercion in the Appalachian region. Findings highlight the negative impact of contraceptive coercion on patients' reproductive autonomy. Promoting contraceptive access, in Appalachia and beyond, requires comprehensive and unbiased contraceptive care.

Assessing trends and reasons for unsuccessful implant discontinuation in Burkina Faso and Kenya between 2016 and 2020: a cross-sectional study.

OBJECTIVES: Contraceptive implant use has grown considerably in the last decade, particularly among women in Burkina Faso and Kenya, where implant use is among the highest globally. We aim to quantify the proportion of current implant users who have unsuccessfully attempted implant removal in Burkina Faso and Kenya and document reasons for and location of unsuccessful removal. METHODS: We use nationally representative data collected between 2016 and 2020 from a cross-section of women of reproductive age in Burkina Faso and Kenya to estimate the prevalence of implant use, proportion of current implant users who unsuccessfully attempted removal and proportion of all removal attempts that have been unsuccessful. We describe reasons for and barriers to removal, including the type of facility where successful and unsuccessful attempts occurred. FINDINGS: The total number of participants ranged from 3221 (2017) to 6590 (2020) in Burkina Faso and from 5864 (2017) to 9469 (2019) in Kenya. Over a 4 year period, the percentage of current implant users reporting an unsuccessful implant discontinuation declined from 9% (95% CI: 7% to 12%) to 2% (95% CI: 1% to 3%) in Kenya and from 7% (95% CI: 4% to 14%) to 3% (95% CI: 2% to 6%) in Burkina Faso. Common barriers to removal included being counselled against removal by the provider or told to return a different day. CONCLUSION: Unsuccessful implant discontinuation has decreased in recent years. Despite progress, substantial numbers of women desire having their contraceptive implant removed but are unable to do so. Greater attention to health systems barriers preventing implant removal is imperative to protect reproductive autonomy and ensure women can achieve their reproductive goals.

Prevalence of non-preferred family planning methods among reproductive-aged women in Burkina Faso: results from a cross-sectional, population-based study.

Family planning researchers have traditionally focused efforts on understanding contraceptive non-use and promoting contraceptive uptake. Recently, however, more scholars have been exploring method dissatisfaction, questioning the assumption that contraceptive users necessarily have their needs met. Here, we introduce the concept of "non-preferred method use", which we define as the use of one contraceptive method while having the desire to use a different method. Non-preferred method use reflects barriers to contraceptive autonomy and may contribute to method discontinuation. We use survey data collected from 2017 to 2018 to better understand non-preferred contraceptive method use among 1210 reproductive-aged family planning users in Burkina Faso. We operationalise non-preferred method use as both (1) use of a method that was not the user's original preference and (2) use of a method while reporting preference for another method. Using these two approaches, we describe the prevalence of non-preferred method use, reasons for using non-preferred methods, and patterns in non-preferred method use by current and preferred methods. We find that 7% of respondents reported using a method they did not desire at the time of adoption, 33% would use a different method if they could and 37% report at least one form of non-preferred method use. Many women cite facility-level barriers, such as providers refusing to give them their preferred method, as reasons for non-preferred method use. The high prevalence of non-preferred method use reflects the obstacles that women face when attempting to fulfil their contraceptive desires. Further research on reasons for use of non-preferred methods is necessary to promote contraceptive autonomy.

Exploring Upward and Downward Provider Biases in Family Planning: The Case of Parity.

INTRODUCTION: Provider bias has become an important topic of family planning research over the past several decades. Much existing research on provider bias has focused on the ways providers restrict access to contraception. Here, we propose a distinction between the classical "downward" provider bias that discourages contraceptive use and a new conception of "upward" provider bias that occurs when providers pressure or encourage clients to adopt contraception. METHODS: Using cross-sectional data from reproductive-aged women in Burkina Faso, we describe lifetime prevalence of experiencing provider encouragement to use contraception due to provider perceptions of high parity (a type of upward provider bias) and provider discouragement from using contraception due to provider perceptions of low parity (a type of downward provider bias). We also examine associations between sociodemographic characteristics and experiences of provider encouragement to use contraception due to perceptions of high parity. RESULTS: Sixteen percent of participants reported that a provider had encouraged them to use contraception due to provider perceptions of high parity, and 1% of participants reported that a provider had discouraged them from using contraception because of provider perceptions of low parity. Being married, being from the rural site, having higher parity, and having attended the 45th-day postpartum check-up were associated with increased odds of being encouraged to use contraception due to provider perceptions of high parity. CONCLUSION: We find that experiences of upward provider bias linked to provider perceptions of high parity were considerably more common in this setting than downward provider bias linked to perceptions of low parity. Research into the mechanisms through which upward provider bias operates and how it may be mitigated is imperative to promote contraceptive autonomy.

Supply-Side Versus Demand-Side Unmet Need: Implications for Family Planning Programs.

Despite its central importance to global family planning, the "unmet need for contraception" metric is frequently misinterpreted. Often conflated with a lack of access, misinterpretation of what unmet need means and how it is measured has important implications for family planning programs. We review previous examinations of unmet need, with a focus on the roles of access and demand for contraception, as well as the role of population control in shaping the indicator's priorities. We suggest that disaggregating unmet need into "demand-side unmet need" (stemming from lack of demand) and "supply-side unmet need" (stemming from lack of access) could allow current data to be leveraged into a more person-centered understanding of contraceptive need. We use Demographic and Health Survey data from seven sub-Saharan African countries to generate a proof-of-concept, dividing women into unmet need categories based on reason for contraceptive nonuse. We perform sensitivity analyses with varying conceptions of access and disaggregate by education and marital status. We find that demand-side unmet need far exceeds supply-side unmet need in all scenarios. Focusing on supply-side rather than overall unmet need is an imperfect but productive step toward person-centered measurement, while more sweeping changes to family planning measurement are still required.

"She told me no, that you cannot change": Understanding provider refusal to remove contraceptive implants.

Enthusiasm for long-acting reversible contraception (LARC) is growing among donors and NGOs throughout the global reproductive health field. There is an emerging concern, however, that the push to insert these methods has not been accompanied by a commensurate push for access to method removal. We use data from 17 focus group discussions with women of reproductive age in an anonymized African setting to understand how users approach providers to request method removal, and how they understand whether or not such a request will be granted. Focus group participants described how providers took on a gatekeeping role to removal services, adjudicating which requests for LARC removal they deemed legitimate enough to be granted. Participants reported that providers often did not consider a simple desire to discontinue the method to be a good enough reason to remove LARC, nor the experience of painful side-effects. Respondents discussed the deployment of what we call legitimating practices, in which they marshalled social support, medical evidence, and other resources to convince providers that their request for removal was indeed serious enough to be honored. This analysis examines the starkly gendered nature of contraceptive coercion, in which women are expected to bear the brunt of contraceptive side-effects, while men are expected to tolerate no inconvenience at all, even vicarious. This evidence of contraceptive coercion and medical misogyny demonstrates the need to center contraceptive autonomy not only at the time of method provision, but at the time of desired discontinuation as well.

Contraceptive method denial as downward contraceptive coercion: A mixed-methods mystery client study in Western Kenya.

OBJECTIVE: This study uses mixed methods to quantify the frequency of method denial in Western Kenya and describe how this barrier impacts contraceptive access. STUDY DESIGN: We estimate the frequency of method denial using data from mystery clients deployed to 57 randomly selected public-sector facilities located in Western Kenya. These quantitative data are triangulated with data from 8 focus group discussions, 19 key informant interviews, and 2 journey mapping workshops with contraception clients and providers. RESULTS: In 21% of mystery client visits, the client was denied their preferred contraceptive method. In 13% of visits, mystery clients were unable to procure any method. Method denial was primarily motivated by provider-imposed requirements for HIV or pregnancy testing, or by provider bias against young, unmarried, or nulliparous women. Method denial also occurred because of provider reluctance to offer certain methods. Focus group discussion participants and interviewees confirmed the frequency and reasons for method denial and identified this practice as a substantial barrier to reproductive autonomy. CONCLUSION: Method denial disrupts contraceptive access among women who have already overcome financial and logistical barriers to arrive at a health care facility. Further attention to this barrier is required to promote reproductive autonomy among women in Western Kenya. IMPLICATIONS: Providers may impose unnecessary restrictions on contraceptive access that limit the ability of women to achieve their desired family size. Unwarranted method denial occurs in approximately one out of every 5 visits to public-sector facilities in Western Kenya and presents a major impediment to reproductive autonomy and justice.

Sex, poverty, and public health: Connections between sexual wellbeing and economic resources among US reproductive health clients.

OBJECTIVE: To document associations between socioeconomics and indicators of sexual wellbeing. METHODS: We obtained our data from the HER Salt Lake Initiative, a large, longitudinal cohort study of family planning clients in the United States who accessed free contraceptive services between March 2016 and March 2017. Baseline socioeconomic measures included Federal Poverty Level, receipt of public assistance, and difficulty paying for housing, food, and other necessities. Sexual wellbeing measures assessed sexual functioning and satisfaction, frequency of orgasm, and current sex-life rating. Among participants who had been sexually active in the last month (N = 2581), we used chi-square tests to examine bivariate associations between sexual and socioeconomic measures. RESULTS: We found strong and consistent relationships between sexual wellbeing and economic resources: those reporting more socioeconomic constraints also reported fewer signs of sexual flourishing. CONCLUSIONS: Financial scarcity appears to constrain sexual wellbeing. To support positive sexual health, the public health field must continue to focus on economic reform, poverty reduction, and dismantling of structural classism as critical aspects of helping people achieve their full health and wellbeing potential. ClinialTrials.gov Identifier: NCT02734199.

Provider verbal disrespect in the provision of family planning in public-sector facilities in Western Kenya.

Public-sector healthcare providers in low- and middle-income countries are a primary source of family planning but their disrespectful (i.e., demeaning or insulting) treatment of family planning clients may impede free contraceptive choice. The construct of disrespect and abuse has been widely applied to similar phenomena in maternity care and could help to better understand provider mistreatment of family planning clients. With a focus on public-sector family planning provision in western Kenya, we aim to estimate the prevalence and impact of disrespect and abuse from a variety of perspectives and advance methodological approaches to measuring this construct in the context of family planning provision. We combine and triangulate data from a variety of sources across five counties in western Kenya, including 180 mystery clients, 253 third-party observations, eight focus group discussions, 19 key informant interviews, and two journey mapping workshops. Across both mystery client and third-party observations conducted in public-sector facilities in western Kenya, approximately one out of every ten family planning seekers was treated with disrespect by their provider. Family planning clients were frequently scolded for seeking family planning while unmarried or low parity, but mistreatment was not limited to women with these specific characteristics. Women were also insulted for such characteristics as body size or perceived sexual promiscuity. Qualitative data confirmed both that client disrespect is widespread and leads women to avoid family planning services even when they desire to use a contraceptive method, sometimes leading to unintended pregnancies. Key informants attribute disrespectful provider practices to both low technical skill as well as poor motivation stemming from both intrinsic values as well as extrinsic factors such as low wages and high caseloads. Possible solutions suggested by key informants included changes to recruitment and admission for Kenyan medical/nursing schools, as well as values clarification to shift provider motivations. Interventions to reduce mistreatment must be multi-layered and well-evidenced to ensure that family planning clients receive the person-centered care that enables them to achieve their contraceptive desires and reproductive freedom.

Facility readiness to remove subdermal contraceptive implants in 6 sub-Saharan African countries.

OBJECTIVE: This study aimed to estimate the proportion of health facilities without the capability to remove contraceptive implants and those that have the capability to insert them and to understand facility-level barriers to implant removal across 6 countries in sub-Saharan Africa. STUDY DESIGN: Using facility data from the Performance Monitoring for Action in Burkina Faso, the Democratic Republic of Congo, Ethiopia, Kenya, Nigeria, and Uganda from 2020, we examined the extent to which implant-providing facilities (1) lacked necessary supplies to remove implants, (2) did not have a provider trained to remove implants onsite, (3) could not remove deeply placed implants onsite, and (4) reported any of the above barriers to implant removal. We calculated the proportion of facilities that report each barrier, stratifying by facility type. RESULTS: Between 31% and 58% of implant-providing facilities reported at least 1 barrier to implant removal in each country (6 sub-Saharan African countries). Lack of trained providers was the least common barrier to implant removal (0%-17% of facilities), whereas lack of supplies (17%-44% of facilities) and the inability to remove a deeply placed implant (16%-42%) represented more common obstacles to removal. Blades and forceps were commonly missing supplies across all 6 countries. Barriers to implant removal were less commonly reported at hospitals than at lower-level facilities in all countries except Burkina Faso. CONCLUSION: This multicountry analysis showed that facility-level barriers to contraceptive implant removal are widespread among facilities that offer implant insertion. By preventing users from being able to discontinue their implants on request, these barriers pose a threat to contraceptive autonomy and reproductive health.